NCLEX EAQ's - Client Needs - Basic care and
comfort questions with correct answers
Which pain scale would the nurse use when assessing a 4-year-old
child?
1
CRIES
2
FLACC
3
Numerical
4
Wong-Baker Correct Answer-4 - Wong-Baker
The Wong-Baker method is a type of faces pain scale best used in
children as young as 3 or 4 years. It contains several faces that a child
can use to identify his or her pain level. CRIES and FLACC are pain
scales typically used with young infants who are unable to verbalize
pain. The numerical pain scales are best used in older children, teens, or
adults who can accurately assign a number to represent pain level.
Which statements regarding acne are correct? Select all that apply. One,
some, or all responses may be correct.
1
Acne is a hormonal disease.
2
,Acne may be caused by stress.
3
Family history could be a reason for acne.
4
Propionibacterium acnes causes acne.
5
Acne is commonly found on the face, chest, upper back, and neck.
Correct Answer-2 - Acne may be caused by stress.
3 - Family history could be a reason for acne.
4 - Propionibacterium acnes causes acne.
5 - Acne is commonly found on the face, chest, upper back, and neck.
Stress and family history may cause acne formation. The causative
organism is Propionibacterium acnes. Acne is commonly found on the
face, chest, upper back, and neck where there are a higher number of
sebaceous glands. Acne is not a hormonal disease; rather, it is a skin
disease due to hormonal imbalance.
Which domain of the Nursing Interventions Classification (NIC)
taxonomy includes care that supports the health of the community?
1
Domain 1
2
Domain 2
3
,Domain 6
4
Domain 7 Correct Answer-4 - Domain 7
Domain 7 of the NIC taxonomy includes care that supports the health of
the community. Domain 1 includes interventions that support physical
functioning. Domain 2 includes care that supports homeostatic
regulation. Domain 6 incorporates interventions that support the
effective use of the health care delivery system.
A health care provider prescribed a diagnostic workup for a client who
may have myasthenia gravis. Which initial objective would the nurse
establish with the client?
1
"The client will adhere to the teaching plan."
2
"The client will achieve psychologic adjustment."
3
"The client will maintain present muscle strength."
4
"The client will prepare for a possible myasthenic crisis." Correct
Answer-3 - "The client will maintain present muscle strength."
Until confirming the diagnosis, the primary goal should be to maintain
appropriate activity and prevent muscle atrophy. It is too early to
develop a teaching plan; establishment of the diagnosis has not yet
, occurred. The response "achieve psychologic adjustment" is too early;
the client cannot adjust with a confirmed diagnosis. The response
"prepare for a possible myasthenic crisis" is an intervention, not an
objective.
Which client statement indicates understanding of content taught about
removing his or her three-way indwelling catheter and continuous
bladder irrigation (CBI)?
1
"I probably will have diluted urine."
2
"I probably will be unable to urinate."
3
"I probably will produce dark red urine."
4
"I probably will experience some burning on urination." Correct
Answer-4 - "I probably will experience some burning on urination."
Because of the trauma to the mucous membranes of the urinary tract,
burning on urination is an expected response that should subside
gradually. Deliberate dilution of the client's urine ceases after removal of
the three-way indwelling catheter in which the continuous bladder
irrigation is connected. However, the urine may have a slight pink tinge
because of the trauma from the surgery and the presence of the catheter.
An inability to urinate may happen if removal the indwelling catheter
occurs too soon when there is still edema of the urethra or the client
comfort questions with correct answers
Which pain scale would the nurse use when assessing a 4-year-old
child?
1
CRIES
2
FLACC
3
Numerical
4
Wong-Baker Correct Answer-4 - Wong-Baker
The Wong-Baker method is a type of faces pain scale best used in
children as young as 3 or 4 years. It contains several faces that a child
can use to identify his or her pain level. CRIES and FLACC are pain
scales typically used with young infants who are unable to verbalize
pain. The numerical pain scales are best used in older children, teens, or
adults who can accurately assign a number to represent pain level.
Which statements regarding acne are correct? Select all that apply. One,
some, or all responses may be correct.
1
Acne is a hormonal disease.
2
,Acne may be caused by stress.
3
Family history could be a reason for acne.
4
Propionibacterium acnes causes acne.
5
Acne is commonly found on the face, chest, upper back, and neck.
Correct Answer-2 - Acne may be caused by stress.
3 - Family history could be a reason for acne.
4 - Propionibacterium acnes causes acne.
5 - Acne is commonly found on the face, chest, upper back, and neck.
Stress and family history may cause acne formation. The causative
organism is Propionibacterium acnes. Acne is commonly found on the
face, chest, upper back, and neck where there are a higher number of
sebaceous glands. Acne is not a hormonal disease; rather, it is a skin
disease due to hormonal imbalance.
Which domain of the Nursing Interventions Classification (NIC)
taxonomy includes care that supports the health of the community?
1
Domain 1
2
Domain 2
3
,Domain 6
4
Domain 7 Correct Answer-4 - Domain 7
Domain 7 of the NIC taxonomy includes care that supports the health of
the community. Domain 1 includes interventions that support physical
functioning. Domain 2 includes care that supports homeostatic
regulation. Domain 6 incorporates interventions that support the
effective use of the health care delivery system.
A health care provider prescribed a diagnostic workup for a client who
may have myasthenia gravis. Which initial objective would the nurse
establish with the client?
1
"The client will adhere to the teaching plan."
2
"The client will achieve psychologic adjustment."
3
"The client will maintain present muscle strength."
4
"The client will prepare for a possible myasthenic crisis." Correct
Answer-3 - "The client will maintain present muscle strength."
Until confirming the diagnosis, the primary goal should be to maintain
appropriate activity and prevent muscle atrophy. It is too early to
develop a teaching plan; establishment of the diagnosis has not yet
, occurred. The response "achieve psychologic adjustment" is too early;
the client cannot adjust with a confirmed diagnosis. The response
"prepare for a possible myasthenic crisis" is an intervention, not an
objective.
Which client statement indicates understanding of content taught about
removing his or her three-way indwelling catheter and continuous
bladder irrigation (CBI)?
1
"I probably will have diluted urine."
2
"I probably will be unable to urinate."
3
"I probably will produce dark red urine."
4
"I probably will experience some burning on urination." Correct
Answer-4 - "I probably will experience some burning on urination."
Because of the trauma to the mucous membranes of the urinary tract,
burning on urination is an expected response that should subside
gradually. Deliberate dilution of the client's urine ceases after removal of
the three-way indwelling catheter in which the continuous bladder
irrigation is connected. However, the urine may have a slight pink tinge
because of the trauma from the surgery and the presence of the catheter.
An inability to urinate may happen if removal the indwelling catheter
occurs too soon when there is still edema of the urethra or the client
